Provider Demographics
NPI:1225772502
Name:TIENABESO, BOMAONYE (MD)
Entity Type:Individual
Prefix:
First Name:BOMAONYE
Middle Name:
Last Name:TIENABESO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 NW 170TH ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-7410
Mailing Address - Country:US
Mailing Address - Phone:405-476-0822
Mailing Address - Fax:
Practice Address - Street 1:1316 NW 170TH ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73012-7410
Practice Address - Country:US
Practice Address - Phone:405-476-0822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-23
Last Update Date:2022-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program